Provider Demographics
NPI:1548250079
Name:PLYMOUTH MA SNF LLC
Entity type:Organization
Organization Name:PLYMOUTH MA SNF LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:G
Authorized Official - Last Name:SANTILLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-751-3900
Mailing Address - Street 1:123 SOUTH STREET
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360
Mailing Address - Country:US
Mailing Address - Phone:508-879-4050
Mailing Address - Fax:508-879-1534
Practice Address - Street 1:123 SOUTH STREET
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360
Practice Address - Country:US
Practice Address - Phone:508-746-4343
Practice Address - Fax:508-746-8240
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATHENA HEALTH CARE ASSOCIATES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-26
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0734314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110094527CMedicaid
MA225207Medicare Oscar/Certification